<form id="add-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group hide">
        <label class="control-label col-xs-12 col-sm-2">{:__('Presentation_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-presentation_id" data-rule="required" data-source="presentation/index" class="form-control selectpage form-control" name="row[presentation_id]" type="text" value="{:$presentation_id}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Native_language')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-native_language" class="form-control form-control" name="row[native_language]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Source_language')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-source_language" class="form-control form-control" name="row[source_language]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Translation')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-translation" class="form-control form-control" name="row[translation]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Meddra_version')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-meddra_version" class="form-control form-control" name="row[meddra_version]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Meddra_code')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-meddra_code" class="form-control  selectpage  form-control"
                   data-source="meddra/index" data-show-field="en" data-show-field="en" data-primary-key="code"
                   name="row[meddra_code]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Highlighted')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-highlighted" class="form-control selectpicker" name="row[highlighted]">
                {foreach name="highlightedList" item="vo"}
                    <option value="{$key}" {in name="key" value=""}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Event_level')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-event_level" class="form-control form-control" name="row[event_level]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Death')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-death" class="form-control selectpicker" name="row[death]">
                {foreach name="deathList" item="vo"}
                    <option value="{$key}" {in name="key" value=""}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Life_threatening')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-life_threatening" class="form-control selectpicker" name="row[life_threatening]">
                {foreach name="lifeThreateningList" item="vo"}
                    <option value="{$key}" {in name="key" value=""}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Hospitalisation')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-hospitalisation" class="form-control selectpicker" name="row[hospitalisation]">
                {foreach name="hospitalisationList" item="vo"}
                    <option value="{$key}" {in name="key" value=""}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Incapacitating')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-incapacitating" class="form-control selectpicker" name="row[incapacitating]">
                {foreach name="incapacitatingList" item="vo"}
                    <option value="{$key}" {in name="key" value=""}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Birth_defect')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-birth_defect" class="form-control selectpicker" name="row[birth_defect]">
                {foreach name="birthDefectList" item="vo"}
                    <option value="{$key}" {in name="key" value=""}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Other_condition')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-other_condition" class="form-control selectpicker" name="row[other_condition]">
                {foreach name="otherConditionList" item="vo"}
                    <option value="{$key}" {in name="key" value=""}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Startdate')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-startdate" class="form-control datetimepicker form-control"  data-date-format="YYYY-MM-DD" data-use-current="true" name="row[startdate]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Enddate')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-enddate" class="form-control datetimepicker form-control"  data-date-format="YYYY-MM-DD" data-use-current="true" name="row[enddate]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Duration')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-duration" class="form-control form-control" name="row[duration]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Duration_unit')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-duration_unit" class="form-control form-control" name="row[duration_unit]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Outcome')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-outcome" class="form-control selectpicker" name="row[outcome]">
                {foreach name="outcomeList" item="vo"}
                    <option value="{$key}" {in name="key" value=""}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Medical_confirmation')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-medical_confirmation" class="form-control selectpicker" name="row[medical_confirmation]">
                {foreach name="medicalConfirmationList" item="vo"}
                    <option value="{$key}" {in name="key" value=""}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Country_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-country_id" data-source="countrycode/index" data-field="name_cn" class="form-control selectpage form-control" name="row[country_id]" type="text" value="">
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
